Magnitude and associated factors of sexual violence among female housemaids attending night school in Bahir Dar City, Northwest Ethiopia: Institution-Based Cross-Sectional Study, 2022

Background Sexual violence is a major public health problem that affects the health and well-being of millions of young people. Housemaids are the most vulnerable group to sexual violence due to their nature of work. It leads to various physical, mental, sexual, and reproductive health problems, especially in our country’s context. However, they have limited information regarding the magnitude and the factors associated with sexual violence among housemaids. As a result, the purpose of this study was to determine the magnitude and risk factors for sexual violence among female housemaids attending night school in Bahir Dar, Northwest Ethiopia, in 2022. Method An institution-based cross-sectional study design was conducted among 340 housemaids attending night school in Bahir Dar city from May 15 to June 20, 2022. Participants were selected using simple random sampling through computer-generated techniques. An interviewer-administered, structured questionnaire was used. Data were entered, coded, and cleaned using EPI Data version 4.6.0.2, and exported to SPSS version 26 for further analysis. Both bivariable and multivariable logistic regression were done to identify factors associated with sexual violence. P-value and 95% confidence interval were used to declare the statistical association. Result The magnitude of sexual violence after being a housemaid was 30.3% with a 95% confidence interval (25.3–35.38). Ever had sex [Adjusted Odds Ratio(AOR) = 4.67; 95%; Confidence Interval(CI) (2.60, 8.39)], no discussion of sexual and reproductive issues [Adjusted Odds Ratio(AOR) = 2.32; 95%; Confidence Interval(CI) (1.29, 4.16)], poor social support [Adjusted Odds Ratio(AOR) = 2.69; 95%; Confidence Interval(CI) (1.32, 5.52)], were identified as factors associated with sexual violence among housemaids. Similarly, academic performance [Adjusted Odds Ratio (AOR) = 0.96; 95%; Confidence Interval (CI) (0.93, 0.99)], and distance to reach school [Adjusted Odds Ratio (AOR) = 2.04; 95%; Confidence Interval (CI) (1.19, 3.48)] were identified as factors associated with sexual violence among housemaids. Conclusion This study identified that the magnitude of sexual violence among housemaids was high. Housemaids who ever had sex, no discussion of sexual and reproductive health (SRH) with anyone, poor social support, poor academic performance, and distance to reach school were factors associated with sexual violence. Therefore, creating a sexual and reproductive health (SRH) discussion session for housemaids is important for securing their sexual rights.

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Consult the submission guidelines for detailed instructions.Make sure that all information entered here is included in the Ethics approval and consent to participate The study was approved by the Institutional review board (IRB) of Bahir Dar University, College of Medicine and Health Science [REF.178/2021].Information about the study was explained to each study participant in the information sheet.Written informed consent was obtained from Adolescents aged 18 years and above (participants under the age of 18 were given verbal assent and written informed consent was obtained from their parents or guardians on their behalf).
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Methods section of the manuscript.

Results:
The study included 631 teenagers, with a response rate of 91.18%.Suicidal behaviour was prevalent in 19.8% of the population (95% CI: 16.6, 22.8).When compared to their peers, adolescents with a family history of suicidal attempts had a 5.66 times (AOR = 5.66, CI = 2.44, 13.10) higher risk of suicidal behaviour.Similarly, adolescents who experienced stressful life events had a higher risk of suicide conduct (AOR = 2.91, CI = 1.45-4.91)than their peers.Adolescents who had negative childhood experiences exhibited a sevenfold (AOR = 7.11, CI = 3.56-14.20)higher risk of suicide behaviour than their peers.Adolescents who do not have a good relationship with their parents have a higher risk of developing suicidal behaviour (AOR = 5.59, CI = 2.59-12.08).Adolescents with significant interpersonal stress had around twice the chances [AOR = 2.17, 95% CI 1.07.4.40] of suicide behaviour as their peers.
Adolescents who expressed more anger had 7.

Conclusion and Recommendation:
The prevalence of suicidal behavior was high in this study showing a significant public health issue among adolescents that requires a great emphasis.

Introduction
Adolescence is a period of transition in the life of a human during which people obtain physiological and psychosocial maturity (1) .One in six people are aged 10-19 years.Multiple physical, emotional and societal changes, including exposure to poverty, abuse, or violence, can make adolescents prone to different mental health problems (2). it is a period of complex and an exceptional and developmental time, during which individuals can undertake different danger practices, including suicidal behavior, which covers suicidal ideation, suicide attempts and suicide itself (3) .Suicidal ideation denotes thoughts of engaging in behavior intended to end one's life, whereas suicide planning is defined as the preparation of a specific method through which one plans to die (4).
Suicidal behavior is among the leading cause of damage and death worldwide.It is a public health issue that is estimated to contribute more than 2.4% to the global burden of disease by the year 2020 (5).It is currently the 10th most common cause of mortality resulting in the loss of approximately one million lives every year (6).Globally there have been an estimated 804 000 suicide deaths arose in 2012, representing a twelve-monthly global age-standardized suicide rate of 11.4 per 100 000 population (15.0 for males and 8.0 for females).However, since suicide is a sensitive issue, and even illegal in some countries, it is very likely and under-reported.Every 40 seconds a person dies by suicide somewhere in the globe and many more attempt suicide.
Suicides occur all over the world and throughout the entire life.Among young people 15-29 years of age, suicide is the second leading cause of death globally and represents a major nationwide health concern according to WHO (7,8).Worldwide, about 4 million adolescents attempt suicide annually, resulting in at least 100,000 deaths (9).Suicide results for an estimated 6% of all deaths among young people globally (10).In low-and middle-income countries adolescent suicide account for 78% of all suicides (11).
In Africa, the overall magnitude of suicide ranged from 2-3% [range 0.7-6.0%](12).Sub-Saharan Africa there are over 34,000 (IQR 13,141 to 63,757) suicides per year, with an overall incidence rate of 3.2 per 100,000 populations (13).Young people are self-harming and taking their own lives at alarming rates.According to WHO Global health estimates in 2015 around 67,148 adolescent deaths were reported, among those 11,920 adolescent aged 10-14 years and the rest 55,228 were aged 15-19 years (14) .
Suicide is a principal cause of death among adolescents.Self-harm is the most important risk factor for suicide, yet the majority of self-harm does not come to the attention of health services (15).Suicidal behavior, deliberate self-harm and non-suicidal self-injury are significant precursors of suicide in children and adolescent (16).It has been reported as a leading cause of psychiatric emergencies for adolescents and the strongest predictor of future suicide attempts and suicide death (17).
Suicidal thoughts and suicidal behavior's develop during adolescence and peak late in adolescence and early adulthood (18).Adolescent suicidal behavior is a neglected public health issue especially in middle and low-income countries including Ethiopia (19). it is a multipart and multidimensional phenomenon stemming from the interaction of several factors (20).
Worldwide, the possible risk factors of suicide include victimization (bullying, sexual harassment), poor psychological state related to depression, phobic disorders, anxiety, alcohol use disorder, child abuse, impulsivity, lack of parental understanding (1).Many studies have demonstrated that mental state problems, substance use, genetic and biological factors, poor physical health or physical disability, and family-environmental factors are associated with increased risk of suicidal behaviors in adolescents (6,21).Different Evidence shows that adolescents of both genders who had suicide ideation and attempts are significantly more likely to commit suicide than those without suicidal ideation and attempts (22).
Reducing suicides is therefore a key public health target.Healthcare systems and services need to be strong and able to incorporate suicide prevention as a core component.Universal health coverage (UHC) ensures that the most vulnerable can access care.Communities play a critical role by addressing stigma and isolation, improving knowledge and awareness, and providing social support to vulnerable individuals.A tool kit to engage communities in suicide prevention has been made available by WHO (14).
In May 2013, the 66 th World Health Assembly formally adopted the first-ever Mental Health Action Plan of the World Health Organization (WHO), Suicide prevention is an important component of the Mental Health Action Plan, with the goal of reducing the rate of suicide in countries by 10% by 2020 (7).
The suicide rate, however, is rising most rapidly among young persons, particularly males 15 to 24 years of age, and the rate is still rising (12).Even though LMICs account for the bulk of suicides, high-income Western nations are the source of most of the knowledge about suicidal behaviours.Because there aren't many researches among teenagers in Ethiopia, little is known regarding the prevalence and determinants of suicide behaviour (suicidal thought, suicidal plan, and suicidal attempt).Therefore, the goal of this study was to evaluate the incidence of suicidal conduct in teenagers and its contributing factors on a local level.

Study design and setting Area
We Eligible adolescents in the selected household were further selected and interviewed.Only one adolescent member of the house hold was selected by lottery method for the interview towards suicide behavior.Data was collected by trained health extension workers and psychiatry nurses with interview by semi-structured questionnaire which was translated into Amharic version (local working language).

Measurements
Suicidal behavior of adolescent was assessed by using the short version of the mini-international neuropsychiatric interview (MINI).itconsists of six items that are scored "yes or no" Among those items, 1-5, record whether an event has occurred during the last month, and item 6 records the lifetime occurrence of the event.If the participant response one "yes" answer from six item (MINI) questions considered as risk for suicidal behavior.MINI has good validity, reliability, and reliability (chronbach's alpha = 0.84) (24).Social support assessed by using oslo-3 social support scale with sum of 3-14, that consist three items; poor(3-8), moderate (9-11) and strong(12-14) (25).Depression was assessed by a nine-item Patient Health Questionnaire-9, which has four response categories referring to the amount of time that the symptom was present (not at all (0), several days (1), more than half of the days (2), nearly every day (3)), with a total score ranging from 0 to 27 (26).For Assessment of adverse child hood experience adverse childhood experience (ACE) Questioner was used (27).self-esteem was assessed by using Rosenberg self-esteem scale people scoring between 15 and 25 is average.A score of less than 15 suggests low self-esteem and score greater than 25 suggests high self-esteem (28).Anger expression was assessed by using the Spiel Berger Anger-Out Expression Scale, which has 8item; scale evaluates respondents' coping methods, particularly outward expressive behavior, when angry.Low anger expression (scores < 10), moderate anger expression; and high anger expression (scores ≥15) (29).Stressful life events of participants were assessed by SLESQ.The SLESQ self-report measure for non-treatment seeking samples that assesses lifetime exposure to traumatic events.Eleven specific and two general categories of events, such as a life-threatening accident, physical and sexual abuse, witness to another person being killed or assaulted (30).
Interpersonal stress was asses by using Bergen Social Relationships Scale BSRS.The scale consists of six items.Individual high scores (above mean) of BSRS has high interpersonal stress (31).Clinical variables like, family history of suicidal attempt and other factors like growing up with their parent were assessed by asking the participants.

Analysis
The collected data was entered into Epi-data version 3.1, exported to SPSS software version 24.0, and checked for inconsistencies and missing values by running frequencies and other data explorations.Inconsistencies and missing values was cleaned by checking the original questionnaire.Frequency distributions, mean, median and interquartile range (IQR) was computed.
Beyond descriptive statistics, associations between the dependent variables and the independent variables were analyzed by calculating the Odds Ratios and 95 % confidence interval.First, Bivariate analysis was performed on each variable and a respective crude odds ratio (COR) was calculated.Independent variables with marginal associations (P ≤ 0.20) in the bivariate analysis were entered in a multivariate logistic regression analysis in order to detect independent factors of suicidal behavior.The significant association of independent variables with the dependent variable was assessed by using 95% confidence interval and a respective adjusted odds ratio (AOR).A two tailed-sided p-value of ≤0.05 will be taken as statistically significant.

Ethical considerations
Ethical clearance was obtained from Institutional review board (IRB) of Bahir Dar University, College of Medicine and Health Science.Then letter of permission was obtained from Bahir Dar city administration health office and permission was granted from the city administrator.The aims of the study were explain for the study participants and data were collected after assent and written consent.Adolescents aged 18 years and above were gave informed written consent to participate.Participants under the age of 18 were verbal assent to the study and then written consent was obtained from their parents /guardians/ on their behalf.Both adolescents and parents were informed that they had the right to refuse to answer any question at any time.Referral was given for participants who had suicidal behavior and depressive symptoms.

Socio demographic Characteristics of the Respondents
In this study, out of 692 individuals, 91.2% (631) responded to the suicidal behaviour interview.
More than half of the respondents were in the middle adolescent age group, with a mean (SD) of 16.1 (2.0) years.Almost all (99.4%) of the respondents were unmarried.The majority (83.7%) of the respondents was living with their parents; 6.5% lived with someone other than their parents; and the rest (9.8%) lived alone.More than half (55.2%) of the participants were female (Table 1).

Psychosocial and Substance Related Factors
This study found that 13.5% of the participants have a family history of suicidal attempts, and 0.3% have a family history of committing suicide.Close to 80% of participants grew up with their biological parents.(106/125) had adverse childhood experiences, 22.4% (28/125) had ever used alcohol, more than one-third of them had no good relationship with their parents (48/125), and 76% (95/125) had stressful life experiences.53.6% ( 67/125) and 33.6% ( 42/125) had moderate and high anger expression behaviours, respectively.For more detail about the distribution of suicidal behaviour by gender and anger, see Figs. 1 and 2, respectively.

Factors Associated with suicidal behavior among Adolescent participant
In bi-variable logistic regression Age, sex, living status, ever use of alcohol, family history of suicidal attempts, growing up with a parent, relationship with a parent, social support, adverse childhood experience, stressful life experience, anger out expression behaviour, depression, interpersonal stress, and current use of tobacco were candidates for multiple variable regression at p < 0.2.In the multivariate analyses, family history of suicidal attempts, facing stressful life experiences, having adverse childhood experiences, having poor social support, not having a good relationship with their parents, depression, interpersonal stress, and having high anger expression behaviours were found to be significantly associated with suicidal behaviour at p < 0.05.
Adolescents with a family history of suicidal attempts had a 5.66 times (AOR = 5.66, CI = 2.44, 13.10) higher risk of having suicidal behaviour compared to those who had no family history of suicidal attempts.Similarly, adolescents with stressful life experiences had higher odds (AOR = 2.91, CI = 1.45-4.91) of having suicidal behaviour compared to their counterparts.Adolescents with adverse childhood experiences (abuse, neglect, and household dysfunction) had a sevenfold (AOR = 7.11, CI = 3.56-14.20)higher risk of having suicidal behaviour compared to their counterparts.
Participants who lacked a good relationship with their parents had higher odds (AOR = 5.59, CI = 2.59-12.08) of developing suicidal behaviour compared to those who had a good relationship with their parents.Participants who had high interpersonal stress had approximately twice the odds [AOR = 2.17, 95% CI = 1.07.4.40] of suicidal behaviour compared to those who had low interpersonal stress.
Adolescents who had higher anger expression behaviour had 7.  3).

Discussion
The main objective of this study was to assess the prevalence and associated factors of suicidal behaviour among adolescents in Bahir Dar city.The prevalence of suicidal behaviour was 19.8% (125) (95% CI: 16.6-22.8)and the magnitude was different among males and females [males = 12.72%, females = 25.57%].This finding was consistent with a study conducted in Ethiopia among adolescent high school students in Dangila Town, which showed that 16.2% had attempted suicide and 22.5% had suicidal ideation (23).The finding of this study was also consistent with another study conducted in Ghana among adolescent high school students who reported suicidal behaviours: 18.2%, 22.5%, and 22.2% for suicidal ideation, suicidal plan, and suicidal attempt, respectively (32);Mozambique (17.7%suicidal ideation and 18.5% suicidal attempt) (33)and Togo (16.5% suicidal thought) (34).
The finding in this study was higher than school-based study done in Kut City, reported suicidal behavior to be 8.3% (9) and Tunisia (9.6% suicidal ideation and 7.3% suicidal attempt) (35).In the contrary, the finding was lower than studies done in Liberia where prevalence of suicidal attempt and suicidal ideation were 33.7% and 26.8% among adolescent students respectively (36), Lebanese 28.9% suicidal ideation(1), Benin (23.2% suicidal thought and 28.3% suicidal attempt) (6).Perhaps, the discrepancy might be due to difference in socio-demographic, economic and cultural characteristics of respondents, sample size, study setting, and might also be due to difference in measurement tools used mini-international neuropsychiatric interview (MINI) Suicidal Scale was used in this study (24).
In the multivariate analyses, several factors were found to be significantly associated with suicidal behavior.Having a family history of suicidal attempts, facing stressful life experiences, having adverse childhood experiences, poor social support, not good relationship with their parent, having depression, and having high anger out expression behavior is significantly associated with suicidal behavior.
This study found that the odds of suicidal behavior were 12.42 times higher among adolescents who had poor social support compared to those who had good social support [AOR=12.42,CI=5.95,25.95].Previous studies (5,23,37), also have found poor social support is positively associated with suicidal behavior.Adolescent who had no good relation with a parent had 5.59 times higher risk for suicidal behavior than those who had a good relationship with their parent [AOR=5.59,95% CI (2.59, 12.08)].the finding of the study was supported by the previous study done in china and Japan (17,38).
Adolescents who had a history of suicidal behavior in their family tried to end their life 5.66 times more likely than adolescents having no family history of suicidal behavior [AOR=5.66,95% CI (2.44, 13.10)] and no significant associations were observed between suicidal attempt and suicidal ideation and family history of suicidal behavior in the study conducted in dangila town (23) but other studies reported that, there were significant associations (37).The Possible

Limitation of the study
This study is not without its limitations.Because it is cross-sectional due to that causal relationships cannot be established between independent factors and suicidal behaviors.
Information bias may occur during data collection.This study did not account for the presence of psychiatric or psychological disorders other than depression, such as schizophrenia, which has been associated with suicidal behavior.This study was conducted in one city in Ethiopia, which limits its generalizability to other settings.

Conclusion
The prevalence of suicidal behavior was relatively high in this study showing a significant public health concern among adolescents in Bahir Dar city that requires a great emphasis.No social support, depression, having family history of suicide, not good relationship with their parent, adverse childhood experience (emotional, physical abuse and house hold dysfunction) and experiencing stressful live events were significant with suicidal behavior.Therefore, the information obtained could make a meaningful contribution to suicide prevention program either at community level or at institutional level.

Recommendation
For Bahir Dar city administration  To work collaboratively with mental health professionals to strengthen provision of education for all community related to social support and provide information on suicidal behavior and its intervention.

For family
 Listen carefully and talk openly with your children about their thoughts and feelings (specifically about suicide and/or self-harm) and make good relationship with them.

For health professionals
 Health care providers should spent time with close relatives of adolescents to let them know the importance of social support and maintaining good relationship with their child.
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3 times the chances of reporting suicide conduct (AOR = 7.30, CI = 2.51-21.22)than those who expressed less anger.Suicidal activity was five times more likely in those who experienced depression [AOR = 5.32, CI = 2.64-10.70].Adolescents with low social support were approximately 12.42 times [AOR = 12.42, CI = 5.95-25.95]more likely to report suicide behaviours than those with high social support.
have conducted a community based cross-sectional study in Bahir Dar city Northwest Ethiopia which is 565 kilo meters from Addis Ababa.According to Bahir Dar city mayor office report in 2019/2020, the estimated population in the city was 373,073.From the total population the number of adolescent (between 10-19 years) was 84,382.The city has one comprehensive specialized hospital, one specialized public hospital, one primary hospital, and four private hospitals, which give service to the city and surrounding population.However, only the comprehensive specialized and specialized hospitals have inpatient psychiatric service.Study was carried out from May1-30, 2021.ParticipantsThe study was targeting on adolescent age (10-19 years old) residing in Bahir Dar city, North West Ethiopia.Participant's age(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) years residing Bahir Dar selected sub city for at least 6 month during study period were included and those participants who are in severe illness and couldn't communicate well for data collectors were not included.Sample size, sampling procedure and data collectionSample size was determined based on the single population proportion formula by using the following assumptions: N=Zα/2 × P (1-P)/W 2 By taking the proportion 22.5% (23) from previous study which was done in Ethiopia and 95% confidence interval was used, 4% margin of error sample size was calculated as:Where Zα/2 = confidence level(1.96)  at CI of 95% N= Sample size P=22.5% (proportion of adolescent who have suicidal ideation) W= margin of sampling error.1-P= sample error proportion of adolescent who have no suicidal ideation N = (1.96)2(0.225) (1-0.225)/(0.04)2= 419 then multiply by 1.5 for design effect which gives 629.By assuming a 10% non-response rate, the final sample size was 692.Multistage sampling technique was used to select the sub-cities (three) from the total of six and to select respective administrative kebeles (the smallest administrative unit) (six) from total of seventeen.The households in the administrative kebeles were selected by systematic random sampling technique after identifying an initial starting household by use of random number.
3 times the odds of reporting suicidal behaviour (AOR = 7.30, CI = 2.51-21.22)than those who had lower anger expression behaviour.Those who had depression had approximately five times the odds [AOR = 5.32, CI = 2.64-10.70] of suicidal behaviour.Adolescents who had poor social support were about 12.42 times [AOR = 12.42, CI = 5.95-25.95]more likely to report suicidal behaviour than participants who had good social support (table Almost all participants (99.7% have good relationships with peers.Large proportions of respondents report moderate social support.The use of tobacco, alcohol, and chat was 4.4%, 9.2%, and 5.1%, respectively (see table2).

Table 2 .
Frequency distribution of psychosocial and substance-related factors among adolescent participants in Bahir Dar city, Northwest Ethiopia, 2021 (n = 631).

Table 3 .
The bi-variable and multivariable logistic regression analysis results of suicidal behaviour and associated factors among adolescent participants in Bahir Dar city, Northwest P value is significant at P<0.05 ** P value is significant at P<0.01 P value of Hosmer and *